PATIENTS WITH ORAL/FACIAL PIERCINGSGingival recession and/o are another reported r periodontal defects complication of oral jewelry. For individuals wearing long barbells for a period

Home Study Solutions.com, Inc. 1

PATIENTS WITH ORAL/FACIAL PIERCINGS

2 Credits

by Wendy Paquette, LPN, BS

Erika Vanterainen, EFDA, LPN

Home Study Solutions.com, Inc. P.O. Box 21517

St. Petersburg, FL 33742-1517 Phone 1-877-547-8933

Fax 1-727-546-3500 www.homestudysolutions.com

Florida CEBP #122

A National Continuing Education Provider

2/27/2000 to 5/31/2023

California CERP #3759

November 2015 to December 2019 Home Study Solutions.com, Inc. is

an ADA CERP recognized provider.


Fourth Edition Revised 2015 Third Edition revised 2012

Second Edition revised 2001 Copyrighted 1999 Home Study Solutions.com, Inc.

Expiration date is 3 years from the original release date or last review date, whichever is most recent.

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Home Study Solutions.com, Inc. P.O. Box 21517

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Fax 1-727-546-3500 www.homestudysolutions.com

Printed in the USA

mailto:[email protected]


PATIENTS WITH ORAL/FACIAL PIERCINGS Course Outline 1. OVERVIEW

2. ANATOMY OF THE TONGUE

3. ANATOMY OF THE LIP

4. THE PIERCING PROCEDURE

• Complications and Risks Associated with Oral Jewelry

• What role does tongue piercing play with tongue cancer?

5. CONCLUSION

6. BIBLIOGRAPHY

7. SELF STUDY EXAMINATION

OBJECTIVES: A. UNDERSTAND CURRENT TRENDS THAT AFFECT PATIENTS WITH

ORAL/FACIAL PIERCING B. RECOGNIZE COMPLICATIONS THAT CAN OCCUR AS A RESULT OF A

ORAL/FACIAL PIERCING C. REVIEW PATIENT EDUCATION AND TREATMENT OPTIONS


THIS PAGE INTENTIONALLY LEFT BLANK


OVERVIEW

Body and oral/ facial piercing is a trend that became popular in the 1990’s.

Every generation has to make a statement. Just look around and you are bound to

see young people of all nationalities with pierced ears, eyebrows, noses, lips,

cheeks, belly buttons, breasts and tongues. Most young people do whatever it

takes to be cool and fit in. Health risks or potential problems are usually not taken

seriously in their decision making process.

The purpose of this course is to educate members of the dental/medical

profession as to the health risks that may occur in a patient with body piercings. The

anatomy of the oral cavity, which pertains to oral piercing, will be discussed along

with the potentially affected nerves, and other problems that may result from this

form of expression.

It has not been a secret that members of the dental and medical community

are strongly opposed to body piercing. In fact, the American Dental Association

cited oral piercing as a public health hazard. At the 139th annual session held in San

Francisco, the 143,000-member association passed a resolution opposing the

practice. “The piercing of oral structures presents the potential for infection because

of vast amounts of bacteria in the mouth and may cause airway obstruction because

of swelling,” according to Gary C. Armitage, DDS, chairperson of the American

Dental Association’s council on scientific affairs.

The oral region of the head has many structures within it, such as the lips,

oral cavity, palate, tongue, floor of mouth, and portions of the throat. These areas

are more vulnerable to infection than other parts of the body, although the belly

button, eyes brows and breasts are also vulnerable to infection as is any open

wound.

ANATOMY OF THE TONGUE When studying the tongue, several anatomical structures are observed as

well as underlying blood vessels and nerves that communicate for sensory functions.

The tongue attaches at the pharyngeal portion of the throat that is the base of the

tongue. The body of the tongue lies freely in the oral cavity and is able to move

about easily. Separating the body of the tongue from the base of the tongue is a V-


shaped groove called the sulcus terminalis. The tip or apex of the tongue, the

lateral borders and the dorsal or top of the tongue contain specialized mucosa called

lingual papillae.

At the sulcus terminalis, a point in the V-shape structure contains a

depression called the foramen cecum where circumvallate lingual papillae line up

on the anterior side near the lingual tonsil area at the base of the tongue. The ventral

or lower side of the tongue has many blood vessels and nerves. A structure called

the plica fimbriata is a fold with fringe-like projections and is beside each lingual

vein. A Parasympathetic nerve called the chorda tympani nerve communicates

with these structures and allows for taste as well as submandibular and sublingual

glandular functions. This nerve moves along the floor of the mouth with the lingual

nerve to give the body of tongue taste sensation.

Fig 1.1 Anatomy of the Tongue

The lateral borders of the tongue contain foliate lingual papillae that are

readily seen on children’s tongues, as the ridges are more prominent. The dorsal

surface has median lingual papillae that are sensory organs associated with taste

as well as other sensory functions. The tongue is divided by a depression called the

median lingual sulcus. The filiform lingual papillae that give the dorsal surface


its velvety texture are slender, threadlike papillae. Fungiform papillae are round

red mushroom shaped dots readily found on the apex of the tongue. Posterior to the

dorsal surface of the tongue’s base is an irregular mass of tonsillar tissue, the

lingual tonsil.

ANATOMY OF THE LIPS

The lips are distinguishable because of their color. The contrast of the

vermilion color and the lighter tones of the facial skin accentuate this region. The

vermilion border is a transition zone from the lips to facial skin. The eyes are drawn

to the lips because of their shape. The lips are considered symmetrical if they are

centered between the eyes and have the same fullness in upper and lower regions.

Above the upper lip is a vertical groove called the philtrum. It extends from

the nasal septum and meets the lip at the tubercle or thick area of the upper

lip. Another groove that is in the area of the nose and lips is the labial commissure

that meets at the corners where the upper and lower lips come together. The

nasolabial sulcus is the groove traveling from the corner of the mouth (labial commissure) to the ala of the nose. Under the lower lip, a groove that separates it

from the chin is the labiomental groove.

Muscles of the facial expression are innervated by the seventh cranial nerve,

VII. Branches of the trigeminal nerve, V, innervate the area of the labial and buccal

mucosa. Several branches of the facial nerve also pass through this area.

Fig 1.2 Anatomy of the Lips


THE PIERCING PROCEDURE Almost all oral piercings are referred to by body modification artists as a

straight piercing. That is, they do not require the boring needle to be bent as is

required with other body piercing sites. The procedure begins with the piercer

assessing the anatomy of the piercing site. The majority of sites are chosen based

on the statistical absence of major vessels or nerves, such as the midline of the

tongue or lip. The introduction of trans-dermal illumination devices to further rule out

the presence of vessels is currently used by a minority of studios. No research exists

to establish the effectiveness of this assessment technique. Still it appears to be a

reasonable further precaution. Once a site is chosen, it is marked and the tissue is

grasped with sponge forceps. The most common initial piercing uses a 14-gauge

boring needle to pierce the tissue. Once the tissue has been pierced, an identically

sized piece of jewelry is used to push the boring needle through the tissue so that

only the jewelry remains. No local anesthetic is used for this procedure. Most oral

piercings require between four and six weeks to heal.

Fig 1.3 Examples of Various Oral/Facial Piercings

After oral/facial piercing, written warnings and instructions are usually given.

Ice is recommended for swelling, but ice should not be chewed. No dairy products

are recommended for 4-7 days after piercing. Use of listerine is recommended after

eating, drinking, and smoking. Gly-oxide/dental oxide should be applied to the

pierced area 3 times a day. Drinking through a straw is to be avoided because this

perpetuates swelling.

Also, individuals with tongue piercings are advised to clean the area daily to

get bacteria causing food particles out. Patients must also check once a day to

make sure the barbell is tight. The end of the stud can come off and be swallowed.


Patients should be advised to tell their dentist that they have an oral piercing

since they can interfere with x-rays. The dentist must instruct the patient to remove

any oral adornments before radiographs are taken.

Complications and Risks Associated with Oral Jewelry

A variety of complications may arise from oral jewelry. Fracturing of anterior

teeth and the posterior cusp tips is the most commonly reported negative sequelae.

There are more than a dozen case reports existing. Persistent tapping of the lingual

barbell against the teeth, in addition to the accidental or intentional biting of the

barbell head, is the apparent cause for this damage. A recent study found that 47%

of individuals wearing a lingual barbell for four years or more exhibited this form of

damage.

Another name for this type of injury is a wrecking ball fracture. Lingual

barbells have also been implicated as a potential etiology for cracked-tooth

syndrome. The factor most closely associated with dental fractures is the length of

the barbell. A proper fitting lingual barbell should have a sheath length just greater

than the thickness of the tongue. Yet many individuals choose to keep the longer

initial barbell as their primary piece of jewelry. Reasons for keeping the initial barbell

include the longer barbell being fun as it can be moved through the tongue a greater

distance, as well as the expense of purchasing a shorter, second barbell. One body

modification artist stated that, despite his studio including the downsizing piece of

jewelry and follow-up appointment in the initial price of the piercing, approximately a

third of his clients fail to return for this appointment. When a longer barbell is noted

by dental practitioners, they should strongly encourage their patients to replace it

with a shorter, less damaging barbell. To further decrease the likelihood of dental

fractures, the piercing community has developed acrylic heads for the barbells,

which are theorized to be less detrimental to the teeth than metal barbell heads.


Fig 1.4 Sublingual Barbell Piercing Fig 1.5 Gingival recession and periodontal defects

Gingival recession and/or periodontal defects are another reported

complication of oral jewelry. For individuals wearing long barbells for a period

greater than two years, more than 50% were found to exhibit gingival stripping on

the lingual aspect of their mandibular incisors. Facial gingival stripping has also been

reported secondary to the wearing of lip labrets or rings. Individuals who habitually

play with their piercings by rubbing them against their teeth and gingiva are most

likely to experience this type of damage. Lip labrets that are placed deeper in the

sulcus are believed to increase the chance for gingival recession. Questions have

also been raised about the possibility that larger gauge jewelry may be less

detrimental to the oral tissues as it distributes any forces present over a larger area.

To date, the size of the labret stud or lingual barbell has not been evaluated. If a

patient does choose to proceed with an oral piercing, a recall to evaluate gingival

health is advisable within two months after the jewelry insertion, in an effort to

intercept any negative effects on the periodontium.

Allergic response/sensitization to jewelry has been reported and is most

frequently linked to the failure of individuals to wear biologically inert jewelry

materials. Silver-coatings and other finishes on poor quality jewelry may wear off

resulting in the exposure of an underlying material that can delay wound healing or

create an allergic sensitivity in patients. Once again, adolescents and youth

engaging in peer-piercing appear at greater risk for this potential complication in that

limited financial resources in this age group may present a barrier to the purchasing

of quality oral jewelry.


Fig 1.6 Illustration of Allergic reaction to tongue piercing

Tissue hyperplasia around jewelry may occur. Mild tissue hyperplasia at the

piercing site may be anticipated. For most types of jewelry this will approximate the

outline of the jewelry resting against the tissue. Severe tissue hyperplasia has been

reported with jewelry engulfed in tissue to the point that surgical excision was the

only viable option to release the jewelry. For this reason, longer lingual barbells and

lip rings instead of labrets are generally placed following an initial piercing.

Fig 1.7 Illustration of tissue hyperplasia

Warnings are given that piercing is a potential “portal of entry” for disease

causing viruses, bacteria, etc., especially oral piercings. It is strongly recommended

not to come in contact with body fluids for three months. Most patients who get

oral/facial piercings do not think about the physiological effects. The tongue piercing


is not only dangerous, but also can lead to malnutrition, anemia or many other

serious complications.

Many facilities that pierce tongues do not always maintain a sterile

environment and the risk of infection is great because of the vast amounts of

bacteria located in the mouth. Local infection can occur because the mouth is hard

to sterilize. Redness and swelling due to local infection can cause serious

complications such as airway obstruction. Systemic infection is always a possibility

and includes the risk of hepatitis and AIDS. The National Institute of Health has

identified oral piercings as a possible vehicle for bloodborne hepatitis transmission.

Common symptoms following piercing include pain, swelling, infection, and

increased saliva flow. Additionally, oral adornments if swallowed can cause

problems. Other adverse outcomes to oral piercing may include trauma to teeth,

interference with chewing and speaking, hypersensitivity to metals, foreign debris in

the pierced site, breathing difficulty because of adornment swallowing and gingiva

(gum) injury.

Many operators are not aware that the tongue has many blood vessels in it

and there may be an increased risk of bleeding problems. An immovable clot within

a vessel may result. A blood clot in this region can produce a life-threatening stroke.

After the oral sites are pierced and jewelry adorned, there is a risk of chipping

teeth or breaking the enamel or fillings of the teeth as one talks and eats. “This

damage may also result in the death of the tooth’s inner pulp, if the trauma to the

tooth is chronic”, according to Margaret J. Fehrenbach, RDH, an educational

consultant.

Several cranial nerves can be affected by piercings. The twelfth cranial

nerve, XII, the hypoglossal, is the motor innervation to both the extrinsic and intrinsic

tongue muscles. Therefore, damage to this nerve can cause inability to perform vital

tongue functions such as speaking and eating. Damage to the ninth cranial nerve,

the glossopharyngeal, IX, can cause loss of taste and general sensation for the

tongue. Loss of taste sensation may also occur if the chorda tympani, a branch of

the facial nerve, is pierced. The lingual nerve, a branch of V3, which runs along with

the chorda tympani, can also be damaged creating loss of sensation to the body of

the tongue and the floor of the mouth. Also, because the lingual nerve innervates


the sublinqual and submandibular salivary glands, salivary flow can be adversely

affected.

The muscles of facial expression are innervated by the seventh cranial nerve,

the facial nerve, VII, which can easily be damaged by piercing. The facial nerve

branches are located superficially and are vulnerable to trauma. Damage to any

branches of the facial nerve can result in facial paralysis in the affected muscle area,

causing inability to use these facial muscles for expression, speaking and/or

chewing. Because the facial nerve passes through the parotid gland damage to the

nerve may affect salivary flow, resulting in permanent drooling.

Fig 1.8 Illustration of cranial nerves

There is a risk factor for bacteremia associated with oral piercings that may

lead to Endocarditis (a serious inflammation of the heart valves or tissues). Bacteria

may enter the bloodstream through the opening resulting from an oral piercing and

cause an infection in the tissues surrounding the heart. In the case of cardiac

irregularities, the infection could prove fatal.

What role does tongue piercing play with tongue cancer? It is important to point out that oral cancer may have signs and symptoms that

may mistakenly be associated with a complication of tongue piercing. According to

Dr. Thomas Stuttaford, the incidence of cancer in the tongue is now increasing.


With 11.5% of cases of cancer affecting the tip, 6.5% affecting the center where the

stud is put, 47% occur on the margins where the tongue rubs against rough teeth.

Fig 1.9-10 Illustrations of tongue cancer

Tongue cancer is usually first noticed as a persistent ulcer, a warty growth, a

firm swelling at the root of the tongue, or a constant white patch. Tongue cancers

are sometimes diagnosed because of enlargement of the glands in the neck. The

pain from the tongue can frequently be referred to the ear so that one of the classic

presumptions of the condition is earache, coupled with an unexplained, or perhaps

unmentioned, ulcer.

REASONS NOT TO PIERCE Excessive drooling Infection Chipped and cracked teeth Pain Injuries to the gums Swelling of tongue Damage to fillings Extreme swelling that can block airway Increased salivary flow Hypersensitivity to metals Scar tissue Nerve damage Risk of endocarditis, an inflammation of the heart valves Can interfere with chewing

A "numb" tongue - temporary or permanent Can interfere with speech Impaired sense of taste Blood loss Touching the mouth jewelry can introduce infection

Jewelry can be swallowed, which can puncture intestine or bowel

Damage to teeth and gums can lead to need for dental reconstruction, which can be expensive

Gum recession

Possible allergic response to metals used in piercing Jewelry can block x-rays

Jewelry needs constant attention and upkeep


CONCLUSION

While it is pretty clear that medicine and dentistry as a whole are adamantly

opposed to body piercings, this craze has not seemed to fade within the past twenty

years, it has only become more creative. Whatever new craze the future has in store

for us, you can rest assured it will probably have opposition.

For now, medical and dental associations say healthcare providers should be

aware of the increasing number of patients with pierced intraoral and perioral sites.

Also, they should be prepared to address dental and medical issues, such as the

potential damage to the teeth, gingiva and the risk of localized and/or systemic

infection that may arise as a result of piercing. Physicians and dentists need to

provide appropriate guidance to patients who are contemplating body piercing and

warn them of potential problems with infection and disease transmission.


DISCLAIMER

Home Study Solutions.com, Inc., and the author do not advocate or discourage the use of

any of the products or modalities described herein. The intent of the author is merely to bring field

practitioners up to date in a concise and factual method. Home Study Solutions welcomes feedback

from users of these products and will make every attempt to be objective in the review and release of

information.

The author has no financial interest in any product or other commodity listed in the course. If

a financial interest does exist, a declaration of that interest must be disclosed in a statement. The

author of this course does not have a commercial interest in any products or services discussed in

this educational activity.

No references will be made in order to promote any product or trade name. It is our policy

that any products mentioned in our courses are for demonstrative purposes only and other like

products may be used. Whenever possible generic names are used to contribute to the impartiality of

the program presented.

There is no substitute for the careful and practical application of new products in appropriate

situations and under direct supervision by a dentist. What works or is favorable for some practices

may not be practical for others, and vice versa. We recommend that all practitioners keep current on

continued research and results of treatment through journals, study groups and all methods of

continuing education.

Home Study Solutions.com, Inc. further cautions its participants about the potential risks of

using limited knowledge from any information contained in this course when incorporating techniques

and procedures into an actual practice setting. No supervised clinical presentation was experienced

with this course and mastery or competence of any techniques or procedures cannot be ascertained.

Home Study Solutions does not have a leadership position or a commercial interest in any

products that are mentioned in this course. No manufacturer or third party has had any input into the

development of course content.

Provider review of all courses are performed every two years to ensure content is current and

accurate. Under no circumstances will a course review exceed three years from the date of last the

update or review.


BIBLIOGRAPHY Baum, MS. A Piercing Issue. Health State 1996; 44 (4); 346-7

Boardman, R. Smith, RA. Dental Implications of Oral Piercings. J Calif Dent Assoc

1997; 25 (3):200-7.

Price, Sheila S., Lewis, Maurice W., Body Piercing Involving Oral Sites. Journal of

Amer Dental Assoc, July 1997 p 1017-20.

Loos, Kim. Effects of Tongue Piercing. ParentsPlace.com. 1999.

Fehrenbach, Margaret J. Tongue Piercing. MS Educational Consultant, 1999.

Stuttaford, Thomas. The Hidden Dangers of Tongue-piercing. The Times, London,

August 20, 1998.

Tang, Alisa. Lurking Perils on Tip of the Tongue. New York Times. Jan 26, 1999, p

D7.

Fehrenbach, Margaret J., Herring, Susan W. Illustrated Anatomy of the Head and

Neck, 2nd edition., W.B. Saunders. pp 17-21.

Buehrens, David. Oral Piercing and Health. JADA , Vol.132, January 2001,

p 127.




Home Study Solutions P.O. Box 21517

St. Petersburg, FL 33742-21517 Phone (727) 547-8933 or (877) 547-8933

Fax (727) 546-3500

PATIENTS WITH ORAL/FACIAL PIERCINGS Self-Study Examination

Instructions: After carefully reading the text, answer the following questions. Fill in the corresponding circle on the answer sheet provided. Good Luck! 1) The American Dental Association sited oral piercing as a public health hazard.

a) True b) False

2) The oral region consists of all except:

a) Lips b) Palate c) Tongue d) Nasal sulcus

3) The tip of the tongue is the:

a) Apex of the tongue b) Base of the tongue c) Body of the tongue d) Lingual papillae

4) The foliate papillae give the dorsal surface of the tongue its velvety texture.

a) True b) False

5) Cranial nerves that can be damaged by oral piercings include all except: a) Vestibulocochlear b) Facial c) Trigeminal d) Hypoglossal e) Glosspharyngeal 6) The upper and lower lips meet at the corner off the mouth which is the:

a) Philtrum b) Labial commissure c) Nasolabial sulcus d) Labial groove




7) Individuals typically have anesthetic during the oral/facial piercing process.

a) True b) False

8) Damage to the lingual nerve can affect salivary flow.

a) True b) False

9) The National Institute of Health has identified piercing as a possible vehicle for:

a) AIDS b) Tuberculosis c) Hepatitis d) None of the above

10) Common symptoms following oral piercing include:

a) Pain and swelling b) Infection c) Increased saliva flow d) All of the above

11) Signs of tongue cancer include all except:

a) A persistent ulcer b) A warty growth c) A constant black patch d) A firm swelling at the root of the tongue.

12) Healthcare workers should provide guidance to their patients who are

contemplating oral piercing. a) True b) False




You can now submit your answers online, receive instant grading and your certificate of completion by email. Visit www.homestudysolutions.com and click on “Client login”, “View my courses” then the “Submit” link next to the course on your course list and answer all the questions completely. You can also submit your answer sheet by mail to Home Study Solutions P.O. Box 21517 St. Petersburg, FL 33742 or by Fax (727) 546-3500. Name: ___________________________________ License Type & #________________________________ Course Title: PATIENTS WITH ORAL/FACIAL PIERCINGS Address: _______________________________________________________________________________________ Phone: __________________________________________ Fax:__________________________________________ Please return my course completion certificate to: O The address where my package was delivered or O E-Mail ___________________________________ O Other: _______________________________________________________________________________________ Please darken the circles completely. Choose ONLY ONE best answer. You may not need all 75 of these spaces depending on the number of questions on your test. A B C D E A B C D E A B C D E

1. O O O O O 26. O O O O O 51. O O O O O 2. O O O O O 27. O O O O O 52. O O O O O 3. O O O O O 28. O O O O O 53. O O O O O 4. O O O O O 29. O O O O O 54. O O O O O 5. O O O O O 30. O O O O O 55. O O O O O 6. O O O O O 31. O O O O O 56. O O O O O 7. O O O O O 32. O O O O O 57. O O O O O 8. O O O O O 33. O O O O O 58. O O O O O 9. O O O O O 34. O O O O O 59. O O O O O 10. O O O O O 35. O O O O O 60. O O O O O 11. O O O O O 36. O O O O O 61. O O O O O 12. O O O O O 37. O O O O O 62. O O O O O 13. O O O O O 38. O O O O O 63. O O O O O 14. O O O O O 39. O O O O O 64. O O O O O 15. O O O O O 40. O O O O O 65. O O O O O 16. O O O O O 41. O O O O O 66. O O O O O 17. O O O O O 42. O O O O O 67. O O O O O 18. O O O O O 43. O O O O O 68. O O O O O 19. O O O O O 44. O O O O O 69. O O O O O 20. O O O O O 45. O O O O O 70. O O O O O 21. O O O O O 46. O O O O O 71. O O O O O 22. O O O O O 47. O O O O O 72. O O O O O 23. O O O O O 48. O O O O O 73. O O O O O 24. O O O O O 49. O O O O O 74. O O O O O

25. O O O O O 50. O O O O O 75. O O O O O Please rate the following from A to E (A being best) A B C D E Ordering experience quality & processing timeliness: O O O O O Course objectives were met: O O O O O Clarity and understandability of course content: O O O O O Author/Instructor demonstrated knowledge of subject: O O O O O Course information applicability to daily practice: O O O O O Overall, I would rate this course: O O O O O Course Improvements:__________________________________________________________________________ Suggested Future Topics:________________________________________________________________________ Other Comments (positive or negative): _________________________________________________________ If you made comments, may we use them in our advertising: Yes O No




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PATIENTS WITH ORAL/FACIAL PIERCINGSGingival recession and/o are another reported r periodontal defects complication of oral jewelry. For individuals wearing long barbells for a period